2 MARYLAND VISION INSTITUTE also Billing for PHYSICIAN'S SURGERY CENTER Please review and sign at the bottom. Patient Name: Date of Birth: Acct #: In order to control the cost of billing, we ask that the patient's portion of their bill be paid at the time of service. We are required to collect your copayment, refraction fee $30.00, contact lens fitting fee can range from $30.00 to $200.00, and all other fees at the time of service. If you are unable to pay your Copayment or Refraction fee today, we will be able to bill you for an additional $10.00 fee. Any request for record releases there will be a charge of $10.00 up to the first 50 pages, and.10 cent for each additional page. The undersigned will ultimately be responsible for any bill incurred in this office or at Physician's Surgery Center regardless of insurance. I understand that it is my responsibility to obtain a referral if necessary for payment. Accounts 90 days or older are subject to collection fees. There will be a $25.00 service charge on all returned checks. Payment from my insurance is to be paid directly to Maryland Vision Institute and/or Physician's Surgery Center. I understand that billing any secondary insurance is ultimately my responsibility, however, Maryland Vision Institute and/or Physician's Surgery Center routinely will submit to these Plans if they are able. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when a claim is processed. I authorize Maryland Vision Institute and/or Physician's Surgery Center to release any information, including diagnosis and the records of any treatment or examination to third party payers and/or health practitioners. Often my eye doctor will find it necessary to dilate my pupils during my exam. Dilating drops frequently blur vision for some length of time and may make bright lights bothersome. I understand that due to this, driving may be difficult and have made appropriate arrangements. I hereby authorize my doctor and/or his/her assistant to administer dilating eye drops, since dilation may be necessary to diagnose my ocular medical issues. Signature Date

3 MARYLAND VISION INSTITUTE Please review and sign at the bottom. Patient Name: Date of Birth: Acct #: Insurance Claim Filing Guidelines for Exams Maryland Vision Institute may submit claims to either medical insurance or vision insurance. Unless your medical insurance has a special provision stating they will cover one routine vision exam per year, a medical diagnosis must be present in order for them to pay the claim. The vision plans our office accepts are EyeMed, VSP, MetLife VSP, American Benefit and certain Lions Club memberships (with a confirmation letter stating what they will pay). These plans cover yearly routine vision exams and refractions (testing necessary to complete an updated eyeglass/contacts prescription). They will not pay for the treatment of medical conditions. They will still cover routine exams if the patient has a history of, or are screened for, glaucoma, hypertension and/or diabetes. However, they will not cover the exam if the patient is treated for any of those medical conditions or have diagnostic testing on the same day. If we are treating a medical condition but you also have a refraction performed, your medical insurance may not cover the $30.00 charge for the refraction testing. A refraction is considered a routine vision procedure. If you wish for us to submit your claim to one of the vision plans listed above, please provide our receptionist with your vision insurance information including your policy I.D. number. When you are taken to a treatment room, notify the technician that you do not wish to be treated for any medical condition. Patient or Guarantors Signature Date

4 PRIVACY PRACTICES ACKNOWLEDGEMENT I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. Name DOB Signature Date I hereby authorize the release of information: To: (Relationship: Spouse, Relative, Caregiver or Friend) medical information ONLY Initials billing / financial information ONLY Initials both medical and billing / financial information Initials

Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork. So we may eliminate any potential waiting time, please fax the completed forms

Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit

Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last

MEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day PATIENT REGISTRATION CONFIDENTIAL PLEASE COMPLETELY PRINT THE FOLLOWING AND SIGN BELOW PATIENT INFORMATION

Patient Information PATIENT DEMOGRAPHIC SHEET Last Name First Name MI of Birth Age Social Security Number Married Widowed Single Other: Marital Status Occupation/Retired Employer English Spanish Mail Phone

HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:

Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your

PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company

Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax

Dear Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible. Enclosed is your patient information sheet and medical history questionnaire. Please

St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have

Mark E. Hollingshead, M.D. Cataract & Refractive Surgeon Welcome: We look forward to being of assistance to you on your first visit with Hollingshead Eye Center. In order to provide the best possible service,

WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration

GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:

Welcome to Cedar Run Eye Center. We look forward to your visit with us! Enclosed you will find: Registration Form History Form Patient check list with a map on the back side Patient Name: Date of Appointment:

REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please

NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam today. A complete eye exam involves two components: 1. Refraction this portion of the examination determines the best lens correction

MEDICAL & OCULAR HISTORY QUESTIONAIRRE Name: Date: Age: Preferred Pharmacy Name: Address: 1. Please describe briefly the main reason you are being examined today. 2. Do you have any of the following conditions

(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL

USF Eye Institute and Ear, Nose and Throat Center Neuro-Opthamalogy Dear Neuro-ophthalmology Patients: The following information is to prepare you for your visit with Dr. Drucker. If you have had an MRI,

Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child

ORANGE COUNTY EYE INSTITUTE *Note: It is the patient s responsibility to file insurance claims if we are not contracted with your insurance company. *Note: Be aware that most medical insurance plans do

AARA INFORMATION Due to changes in healthcare privacy and healthcare reform laws, we are now required to gather certain information regarding your race and ethnicity. This information is required as part

NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address

NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)